Information Collection Request

Model Medicare Advantage and Medicare Prescription Drug Plan Individual Enrollment Request Form (CMS-10718)

ICR 202306-0938-006 · OMB 0938-1378 · Active

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0938-1378 can be found here:

Forms and Documents

Document Name	Status
Form CMS-10718 Eligibility and Enrollment Eligibility and enrollment (Part D sponsor) Form and Instruction	Modified
Form CMS-10718 Eligibility and Enrollment Eligibility and enrollment (Part D sponsor) Form and Instruction	Modified
Form CMS-10718 Eligibility and Enrollment Eligibility and enrollment (Beneficiaries) Form and Instruction	Modified
Form CMS-10718 Eligibility and Enrollment Eligibility and enrollment (Beneficiaries) Form and Instruction	Modified
Form CMS-10718 Election Process (MA organization) Form and Instruction	Modified
Form CMS-10718 Election Process (MA organization) Form and Instruction	Modified
Form CMS-10718 Election Process (Beneficiaries) Form and Instruction	Modified
Form CMS-10718 Election Process (Beneficiaries) Form and Instruction	Modified
CMS 10718 - Non-Sub Change Request Memo.docx Justification for No Material/Nonsubstantive Change	2023-06-12
CMS 10718 - Non-Sub Change Request Memo.docx Justification for No Material/Nonsubstantive Change	2023-06-12
CMS Response to CMS-10718 30-day Public Comments.docx Supplementary Document	2022-06-16
CMS Response to CMS-10718 30-day Public Comments.docx Supplementary Document	2022-06-16
CMS-10718_Supporting Statement_A_Race_Ethnicity_June 2022 - Clean.docx Supporting Statement A	2022-06-30
CMS-10718_Supporting Statement_A_Race_Ethnicity_June 2022 - Clean.docx Supporting Statement A	2022-06-30
CMS Response to Public Comments_CMS-10718, OMB 0938-1378.docx Supplementary Document	2022-05-04
CMS Response to Public Comments_CMS-10718, OMB 0938-1378.docx Supplementary Document	2022-05-04
CMS 10718- CY 2023 MA PDP Enrollment Form Crosswalk.docx Supplementary Document	2023-06-12
CMS 10718- CY 2023 MA PDP Enrollment Form Crosswalk.docx Supplementary Document	2023-06-12

IC Document Collections

IC ID	Document Title	Status
242684	Part D Communication Requirements, Review and Distribution of Marketing Materials	Unchanged
242683	Medicare Advantage Communication Requirements Review and Distribution of Marketing Materials	Unchanged
240724	Eligibility and Enrollment Eligibility and enrollment (Part D sponsor) Form and Instruction	Modified
240724	Eligibility and Enrollment Eligibility and enrollment (Part D sponsor) Form and Instruction	Modified
240723	Eligibility and Enrollment Eligibility and enrollment (Beneficiaries) Form and Instruction	Modified
240723	Eligibility and Enrollment Eligibility and enrollment (Beneficiaries) Form and Instruction	Modified
240722	Election Process (MA organization) Form and Instruction	Modified
240722	Election Process (MA organization) Form and Instruction	Modified
240302	Election Process (Beneficiaries) Form and Instruction	Modified
240302	Election Process (Beneficiaries) Form and Instruction	Modified

ICR Details

Status	Active
Agency/Subagency	HHS/CMS
OMB Control No	0938-1378
Type of Information Collection	No material or nonsubstantive change to a currently approved collection
Previous ICR Reference No	202205-0938-003
Agency Tracking No	CM-CPC
Date Submitted to OIRA	2023-06-13
Requested Expiration Date	1969-12-31